The increase in asthma prevalence over the past 20 years could be due to modification of exposure to environmental factors (environmental theory) or to the lost of protective factors (hygienist theory). Among environmental factors this paper reviewed the controversial role of exposure to house dust mite (HDM). If exposure to HDM is deleterious in asthmatics known to be sensitised to this allergen, the effect of HDM exposure on asthma incidence has been challenged recently, based on longitudinal studies showing no correlation between level of exposure to HDM and asthma incidence. Exposure to animal dander may have protective effects. This review has shown that, even if some studies have shown potential protective effect of early exposure, the protection seems to be better in families with a low risk of atopy; almost all studies tend to show a deleterious effect of current exposure; exposure to dog dander may be more protective than cat. These studies cannot give definite conclusions to change current advices of early eviction of HDM and animal dander, especially in families with a high risk of atopy. The deleterious effect of passive smoking on asthma prevalence and severity is undisputable and our efforts should concentrate on obtaining effective eviction of passive smoking. (C) 2004 Elsevier SAS. All rights reserved.

The increase in asthma prevalence over the past 20 years could be due to modification of exposure to environmental factors (environmental theory) or to the lost of protective factors (hygienist theory). Among environmental factors this paper reviewed the controversial role of exposure to house dust mite (HDM). If exposure to HDM is deleterious in asthmatics known to be sensitised to this allergen, the effect of HDM exposure on asthma incidence has been challenged recently, based on longitudinal studies showing no correlation between level of exposure to HDM and asthma incidence. Exposure to animal dander may have protective effects. This review has shown that, even if some studies have shown potential protective effect of early exposure, the protection seems to be better in families with a low risk of atopy; almost all studies tend to show a deleterious effect of current exposure; exposure to dog dander may be more protective than cat. These studies cannot give definite conclusions to change current advices of early eviction of HDM and animal dander, especially in families with a high risk of atopy. The deleterious effect of passive smoking on asthma prevalence and severity is undisputable and our efforts should concentrate on obtaining effective eviction of passive smoking.

L’atteinte des voies aériennes inférieures dans la mucoviscidose est liée à des infections récidivantes voire chroniques et à une inflammation, favorisées par les anomalies du mucus et du liquide de surface bronchique. Elle est précoce et fait le pronostic de la mucoviscidose. Il est essentiel de détecter et de caractériser l’infection et l’inflammation bronchique pour optimiser le traitement. Ceci nécessite une analyse des sécrétions provenant des voies aériennes inférieures. Elle est facile quand le malade est capable de produire spontanément des crachats provenant des voies aériennes inférieures. En effet des études ont montré que les germes retrouvés dans l’analyse des crachats produits spontanément reflètent relativement bien la flore identifiée dans les voies aériennes par fibroscopie [1, 2]. Mais tous les malades ne crachent pas ; c’est le cas des nourrissons et des petits enfants mais aussi d’enfants plus âgés et d’adultes. La proportion de malades capables de cracher augmente avec l’âge mais elle est inférieure à 10 % à l’âge de 6 ans et n’atteint pas 70 % chez les enfants de 12 ans dans l’étude de Sagel et coll. [3]. Il est donc fondamental de trouver des techniques alternatives pour quantifier l’infection.

Basic and clinical research in cystic fibrosis have led to several new hypothesis to improve the management of the disease. The numerous tracks for new therapies may be explained by the lack of firm patho-physiological explanations for the disease and of knowledge of the best targets to get a significant improvement of the patients. After initial great hopes, there has been important limitations and slow down of gene therapy, imposing to go back to research programs on new vectors. New hopes have arisen with protein therapies, including chaperones molecules that can activate mutated CFTR proteins within the cells. New anti-inflammatory therapies are developed, including proteases inhibitors. The prevention of airway colonisation with Pseudomonas aeruginosa is fundamental and could go through the development of specific vaccines, cellular therapies or molecules directly acting on the virulent factors of the bacteria. (C) 2003 Elsevier SAS. All rights reserved.

Basic and clinical research in cystic fibrosis have led to several new hypothesis to improve the management of the disease. The numerous tracks for new therapies may be explained by the lack of firm patho-physiological explanations for the disease and of knowledge of the best targets to get a significant improvement of the patients. After initial great hopes, there has been important limitations and slow down of gene therapy, imposing to go back to research programs on new vectors. New hopes have arisen with protein therapies, including chaperones molecules that can activate mutated CFTR proteins within the cells. New anti-inflammatory therapies are developed, including proteases inhibitors. The prevention of airway colonisation with Pseudomonas aeruginosa is fundamental and could go through the development of specific vaccines, cellular therapies or molecules directly acting on the virulent factors of the bacteria.

Although when an infant or a young child presents with persistent or recurrent wheezing, the probability of asthma is high, one must remain very careful in order not to miss an other etiology. Except for the chest X ray with inspiratory and expiratory studies that is mandatory, the other evaluations should be based on a careful interview and clinical examination. Fiberoptic bronchoscopy may be indicated each time there is a doubt on foreign body aspiration or tracheobronchomalacia.

Infection with respiratory syncytial virus is frequent but most often benign. The serious forms of the illness, which make necessary hospitalisation or care in an intensive Care Unit, appear in infants of less than 6 weeks and especially in those with underlying pathologies, prematurity, congenital cardiopathies or chronic respiratory illnesses. Palivizumab (SYNAGIS) is mouse humanized monoclonal antibody which is used for prevention by monthly injections before and during the epidemic period. In a pivotal study performed on 1502 infants aged less than 6 months and former prematures of less than 36 weeks gestational age (GA) or aged less than 2 years and preventing a bronchopulmonary dysplasia, 1002 infants received 5 monthly injections, compared with 500 infants treated with placebo. There was a significant reduction of 55% risk of hospitalisation with VRS infections in the treated group, but no significant reduction in the number of stays in intensive care or deaths. The recommendation in France now is to use SYNAGIS in children aged less than 6 months, born with or GA of less then 32 weeks or aged less than 2 years and presenting a bronchopulmonary dysplasia. Questions remain on the cost-benefit ratio of this treatment and the favourable effects of this treatment in children who carry other chronic pulmonary or cardiac pathologies.

Although when an infant or a young child presents with persistent or recurrent wheezing, the probability of asthma is high, one must remain very careful in order not to miss an other etiology. Except for the chest X ray with inspiratory and expiratory studies that is mandatory, the other evaluations should be based on a careful interview and clinical examination. Fiberoptic bronchoscopy may be indicated each time there is a doubt on foreign body aspiration or tracheobronchomalacia.

Le diagnostic de tuberculose pulmonaire chez l'enfant demeure un défi. Le score de Keith Edwards utilisé dans plusieurs pays à faibles ressources a une fiabilité controversée.Nous avons réalisé une étude prospective sur un échantillon randomisé de 161 enfants dont 100 tuberculeux pulmonaires et 61 témoins chez qui nous avons appliqué le score de Keith Edwards. Des analyses statistiques univariées, bivariées et multivariées ont été appliquées.Le score était positif chez 85 % des tuberculeux et 32,8 % des témoins. L'âge, la durée de la maladie, l'état nutritionnel, le contage tuberculeux, le test tuberculinique positif et la présence d'adénopathies ont influencé significativement l'association entre le score diagnostique et la tuberculose pulmonaire (p < 0,05). La sensibilité du score était de 85 %, sa spécificité de 67,2 %, sa valeur prédictive positive de 80,9 % et sa valeur prédictive négative de 73,2 %. Les ratios de vraisemblance positive et négative étaient respectivement 2,57 et 0,22.Le score de Keith Edwards pourrait être utile dans le dépistage de masse en santé publique mais il est moins recommandable pour le diagnostic individuel de la tuberculose pulmonaire chez l'enfant compte tenu de sa faible spécificité. Des études plus approfondies sont nécessaires afin de déterminer et valider les caractéristiques symptomatologiques de cette maladie chez l'enfant.The diagnosis of childhood pulmonary tuberculosis remains a challenge. The effectiveness of the Keith Edwards scoring system used to diagnose tuberculosis is controversial. We evaluated this scoring system in the present study.A prospective randomized study was conducted between March 2008 and December 2011 at the Kimpese General Evangelical Hospital in the Democratic Republic of Congo. The results of the Keith Edwards score were considered for the 161 children (100 pulmonary tuberculosis and 61 case controls) who were enrolled in the study. The association between different parameters and the score and between these parameters and pulmonary tuberculosis were statistically analyzed using univariate and multivariate tests.Eighty-five (85%) out of the 100 children diagnosed as having pulmonary tuberculosis and 20 (32.8%) of the case controls had a positive score. The age of the patient, duration of the disease, nutritional status, tuberculosis contact, positive tuberculin skin test, and lymph node enlargement showed a significant statistical association with the score and pulmonary tuberculosis (P < 0.05). The score's sensitivity and specificity were 85% and 67.2%, respectively. The positive predictive value and negative predictive value were found to be 80.9% and 73.2%, respectively. The positive likelihood ratio was 2.57, the negative likelihood ratio was 0.22, and overall agreement was 76.1%.The Keith Edwards score could be good tool for public health purposes, but it might be less effective for individual diagnosis of childhood pulmonary tuberculosis because of low specificity. Further studies are required to evaluate and validate the diagnostic value of clinical and radiological symptoms in childhood pulmonary tuberculosis.